The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

Summary

Summary

History of the flight

The pilot hired a Beechcraft D55 Baron aircraft for travel
associated with business commitments and submitted an instrument
flight rules (IFR) flight plan from Bankstown to Warren and return.
The flight to Warren proceeded normally. The pilot obtained an
amended forecast before the return flight. The forecast indicated
instrument meteorological conditions (IMC) for his arrival.
Accordingly, he replanned via Bathurst in anticipation of an
instrument arrival procedure to Bankstown.

The pilot departed Warren at 1628 ESuT and at 1705 reported 20
NM north west of Bathurst at 9,000 ft. That placed the aircraft
inside controlled airspace without a clearance. The pilot was
subsequently issued a clearance along the planned track.
Approaching Bankstown the pilot encountered IMC and requested a
Bankstown Radar Two arrival, anticipating a cloud break procedure
from a radar vector. However, due to the missed approach flight
path of that procedure conflicting with Sydney airspace
requirements, the Sydney departures (west) controller, after
determining that the pilot did not want the GPS approach, advised
the pilot to expect a clearance for the Runway 11C Radar/Bankstown
NDB/Sydney DME instrument approach. The pilot acknowledged the
instruction. The approach controller subsequently observed the
aircraft on radar to the right of the assigned approach track. He
advised the pilot that he was right of track and cleared him to
leave controlled airspace tracking to Bankstown along that
procedure.

The pilot contacted Bankstown tower and advised that he was
flying the Bankstown Runway 11C Global Positioning System (GPS)
approach. The tower controller, who had been expecting the aircraft
to be on a Runway 11C Radar/Bankstown NDB/Sydney DME approach,
queried the pilot as to which approach he was using. The pilot
confirmed that he was flying the GPS approach.

Recorded radar data showed that the aircraft had closely tracked
the Runway 11C GPS approach path to a point 17 NM from Sydney,
heading about 120 degrees at 2,500 ft. The aircraft then turned
left to a heading of about 065 degrees and descended to 600 ft. The
descent rate during that period was between 2,200 and 3,400 ft per
minute. The aircraft then turned right to about 240 degrees and
climbed to 1,100 ft. The minimum altitude for that segment of the
approach profile was 1,400 ft. The Sydney departures (west)
controller observed the aircraft on radar and advised the Bankstown
tower controller. A short time later, the tower controller heard
the transmission 'India Lima Mike emergency emergency'. Subsequent
transmissions from the tower controller to the pilot went
unanswered.

A witness, located approximately 2.5 km east of the accident
site, reported seeing an aircraft pass overhead on a westerly
heading with its engines surging before stopping. Other witnesses
saw an aircraft apparently attempting to land in a nearby field.
They described its approach as steep and slow. The aircraft
descended into a grass-covered gully and impacted the ground. The
impact collapsed the extended landing gear and the aircraft,
although otherwise intact, was substantially damaged. The pilot,
who was the sole occupant, received severe head and facial
injuries.

Witnesses described weather conditions at the time of the
accident as overcast with light rain falling and visibility
estimated to have been between 3 and 5 km.

The pilot later stated that he had not previously flown a Runway
11C Radar/Bankstown NDB/Sydney DME instrument approach. Although he
had acknowledged the controller's instructions for the approach to
Bankstown, his intention had been to descend to the lowest safe
altitude (LSALT) on that track and, if not in visual contact with
the ground, to climb and divert to Bathurst. He reported that when
he was not visual at 600 ft he commenced a climbing right turn onto
a reciprocal track with the intention of diverting.

The pilot reported that after initiating the climbing turn onto
a westerly heading, the left engine failed. He carried out the
initial actions for engine failure but did not check the fuel
selection at that time. He reported that checking the fuel
selection was an item of his memorised trouble checks that in a
multi-engine aircraft are performed after the initial actions and
prior to feathering and securing the failed engine. However, before
commencing the trouble checks the right engine failed and the pilot
discontinued any further checks. He broadcast an emergency radio
transmission and concentrated on controlling the aircraft. When
clear of cloud, he manoeuvred the aircraft to avoid some towers and
positioned the aircraft for a landing ahead, clear of houses and
power lines.

The pilot later stated that he had intended to change from the
auxiliary fuel tanks to the main tanks before commencing the
approach. However, anxiety at having to fly an unfamiliar approach
in IMC had distracted him and he had forgotten to change tanks. The
pilot had not referred to either the approach or landing checklists
that each included a check of the fuel tank selection.

Pilot experience, qualifications and
recency

The pilot held a Commercial Pilot Licence and a valid Class 2
Medical Certificate. His Command Instrument Rating was endorsed for
ILS, LLZ, VOR and NDB approaches. A log book entry on 24 May 1996
certified him as competent to use the GPS for en route navigation
only. His total instrument flight time was 129 hours. No instrument
flight time was recorded in the 90 days prior to the accident. His
instrument rating renewal on 13 April 1999 had included an NDB
approach. He had subsequently recorded an NDB approach, in flight,
on 13 August 1999 and had made two practice NDB approaches in a
ground procedure trainer on 20 September 1999. Recent experience
requirements in Civil Aviation Orders Part 40.2.1 specified that
the holder of a command instrument rating must not carry out an NDB
approach in IMC unless in the preceding 90 days the holder has
flown that type of approach either in flight or in a synthetic
flight trainer.

At the time of the occurrence the pilot was operating under the
privileges of a Command Instrument Rating (Multi-engine). On 10
March 2000 the Civil Aviation Safety Authority promulgated Civil
Aviation Order 40.2.3 "Private IFR Rating" that allowed private
pilots who had received appropriate training to fly in IMC under
conditions less strict than those required for an instrument
rating. The Private IFR Rating specified a flight review at
intervals of two years. Civil Aviation Advisory Publication
5.13-1(0) Private IFR Rating recommended that recent experience
requirements of the command instrument rating be used for guidance
as to instrument flight time and instrument approaches.

The pilot had recorded 45.7 hours on the Beechcraft Baron type.
His initial Baron endorsement training was undertaken in the B58
model but all his recent time on type was in the D55 model.

Fuel system and management

The D55 Baron fuel system consisted of a separate main and
auxiliary tank in each wing. A selector for each fuel system was
located on the floor between the front seats. The selector had four
positions marked OFF, AUX, MAIN and CROSSFEED. A placard on the
fuel selector directed pilots to use the auxiliary tanks in level
flight only. The Pilot's Operating Handbook advised pilots to
preplan fuel and fuel tank management before the actual flight and
to utilize the auxiliary tanks only in level cruise flight. The
last item of the descent checklist was "Fuel Selector Valves -
MAIN".

Single fuel quantity indicators for both the left and right fuel
systems were mounted on the pilot's lower panel. A toggle switch on
the electrical sub-panel enabled selection of the quantity
indication for either the main or auxiliary tanks.

The later model Beechcraft B58 Baron has a single tank in each
wing, simplifying fuel selection and fuel quantity indication.

Wreckage examination

Examination of the wreckage did not reveal any pre existing
defect that may have contributed to the accident sequence. There
was no fuel in the auxiliary tanks. Approximately 170 litres of
Avgas was recovered from the main tanks. The fuel selectors and the
fuel quantity gauge switch were selected to the auxiliary tank
positions. The wing flaps were not extended.

The aircraft was certified for IFR flight and was equipped with
a GPS receiver that met the requirements for conducting GPS
non-precision approaches. Documentation found in the wreckage
included a set of current approach charts but the investigation was
unable to determine which approach chart the pilot had used for the
approach.

Shoulder harness attachment

The upper attachment of the pilot's shoulder harness failed
during the accident sequence. The harness had no inertia reel and
required manual adjustment. The pilot reported that he had been
unable to adjust the shoulder harness as firmly as he desired.
Examination of the upper attachment found that the installation was
not in accordance with the approved modification and the bolt had
pulled through the window pillar (see photos Fig. 1 and 2 below).
The attachment for the right seat shoulder harness conformed to the
approved modification.

Figure 1: Photograph of the failed shoulder harness
attachment showing (above) where the bolt had pulled through the
pillar.

Figure 2: Photograph of the bolt and harness end
fitting.

Attachments for the shoulder harnesses had been installed in
January 1973. This was carried out to comply with Airworthiness
Directive AD /GENERAL/28 "Safety Belt and Harness Installations"
that was issued in May 1972. The AD required an additional, single,
shoulder strap to be fitted to the front cockpit seats of all
Australian registered aircraft. The aircraft's log book indicated
compliance with the AD in accordance with an approved design
drawing.

Figure 3: Cross-section through pilot's window pillar as
appeared on the approved modification drawing.

Figure 4: Cross-section through pilot's window depicting
the installation as found on VH-ILM.

The investigation was unable to determine how and when this
attachment was altered. Maintenance records showed that since
modification the aircraft had been resprayed and the pilot's side
window panel had been replaced. Either procedure may have required
removal and reinstallation of the attachment. The attachment in the
aircraft, as depicted in the diagram at Fig. 4, was significantly
weaker than the approved method of attachment shown in the diagram
at Fig. 3, thereby reducing the protection provided by the design.
The fact that it was an incorrect installation may not have been
apparent to maintenance personnel. The approved installation
drawings were held by the organisation that originally performed
the modification and were not readily available for reference by
subsequent maintenance personnel.

Maintenance personnel normally referred to the illustrated parts
catalogue for identifying correct components and assemblies. That
catalogue, produced by the aircraft manufacturer, did not
incorporate modifications by other than the aircraft manufacturer.
As such, the modification of the shoulder harness installation did
not appear in the catalogue. Approved maintenance data, as required
under Civil Aviation Regulation CAR 2A, provided guidance as to the
information and documentation required to assist licenced aircraft
maintenance engineers (LAMEs) to carry out aircraft maintenance,
including modifications.

"…the holder of the Certificate of Registration for an
Australian aircraft must:

(a) keep a log book for the aircraft, and
(b) make the log book available, and other documents referred to
in the log book, available to CASA and to persons engaged in
maintenance on the aircraft…."

Investigation into a fatal floatplane accident at Calabash Bay,
NSW on 26 July 1998 (Occurrence 199802830) also found incorrectly
fitted seat belt attachments. The report noted that failure of
these attachments might have contributed to the severity of injury
to the occupants. In both the Calabash Bay accident and this
occurrence, aircraft had been found to have been operated with
incorrectly attached restraint systems.